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South Africa has progressed markedly since the democratic elections in 1994, which heralded equal rights for all citizens, including the right to health care (Delobelle, 2013). This is the key motivation for the national health insurance (NHI) plan reflected in the White Paper on NHI for South Africa (Department of Health [DoH], 2017a), which in 2019 became the NHI Bill. It justifies NHI for South Africa by stating that it is the ‘right of citizens to have access to quality healthcare services’ (DoH, 2017a, p. 1). NHI is based on principles of the right to access health care, described in the Constitutions' Bill of Rights, initiated after the 1994 government changeover (DoH, 2017a).

The newly appointed post-apartheid government introduced its formalised health care reform in order to reduce the glaring discrepancies between South Africas' developing and industrialised world realities. This health care reform aimed to address the needs of previously neglected populations through provision of more equitable health care services for all (Government Communication and Information System [GCIS], 2009). A PHC approach was adopted, signalling a shift from a curative hospital-based structure to a cohesive and accessible community-based system at provincial level (GCIS, 2009; Maillacheruvu & McDuff, 2014). However, social inequalities and health care issues have persisted as a function of poverty (Delobelle, 2013). This is despite post-apartheid majority rule and the governments' attempts to address the social and economic consequences of apartheid, as well as provide accessible health care services, particularly through its PHC and community-based initiatives (Maillacheruvu & McDuff, 2014). The NHI is touted as a significant approach to address health care access challenges. Khoza-Shangase argues in chapter 5 that the NHI has the potential to enhance EHDI. The White Paper on NHI for South Africa (DoH, 2017a, p. 1) and its 2019 Bill assert that ‘good health is an essential value of the social and economic life of humans and is an indispensable prerequisite’. NHI aims to achieve a healthier nation, where people live longer and suffer less illness. This aim correlates very well with the goals of EHDI. NHI also aims to prevent illness and to ensure that patients receive treatment at an early stage of illness to avoid complications. This is consistent with the goals of early intervention for children with hearing impairment. Furthermore, NHI aims to have family health teams in all neighbourhoods providing preventive health services and home-based care, a strategy that improves access to health care services and would, for EHDI, be contextually relevant and responsive. Lastly, NHI encourages the expansion of PHC services, a model of health care that the South African government has adopted.

The South African health care system has been described as reasonably developed, with post-1994 public and private systems that run concurrently (Swanepoel, Störbeck, & Friedland, 2009). The less resourced public health care system is accessed by over 80 percent of the population for a minimal administration fee or for free (DoH, 2017b; Swanepoel et al., 2009). Accessing private health care is affordability based, and private health care expenditure is five times more per person than public health care spending (DoH, 2017b). The NHI proposes a homogeneous approach to health care, where citizens can access health services in both the public and private sectors at the expense of the NHI, regardless of their socio-economic status. It will run as a public, non-profit unit to render guaranteed, quality health care for all South African citizens (DoH, 2017b). This implies that the South African government aims to achieve universal health coverage and access to a high quality of care (Health Systems Trust, 2017).

Nationally, there are more than 400 public and 200 private hospitals (Britnell, 2015). This has clear implications for capacity versus demand. The larger hospitals are managed by provincial health departments, and districts manage the smaller hospitals and PHC clinics (Britnell, 2015). In terms of Treasury distribution of funds, health care sector funding, particularly at a provincial level, is determined according to specific contextual deliberations and service delivery needs (Motsepe, 2017). Funds are thus prioritised differently per province (Mailovich, 2019). This results in differing and non-standardised health care delivery, dependent on provincial priorities, with knock-on effects regarding intra- and intersectoral liaison approaches to health care. Consequently, this funding model tends to widen the apparent health care disparities between provinces when health care services are compared across regions. As such, standardisation is rendered superfluous. Furthermore, this occurs in the context of South Africa trying to attend to the long-term goal of addressing the social determinants of health, which vary between provinces, with some provinces such as Gauteng and the Western Cape being significantly better off than others. Addressing the social determinants of health in South Africa has been acknowledged as a long journey to improve ‘the circumstances in which people grow, live, work and age, and the systems put in place to deal with illness’ (Commission on the Social Determinants of Health, 2008, p. 3).

At present, the audiologists' role in detection and intervention for hearing impairment in the public health care system is formally tiered in a guideline compiled by the National Speech Therapy and Audiology Public Sector Forum (Health) and the Professional Board of the Speech, Language and Hearing Professions (n.d.), as depicted in Table 4.1.

Table 4.1 Audiology services at all levels of health care in South Africa

Level of care	Types of facilities	Audiology service provision
Primary	PHC clinics	Development, monitoring and evaluation of ototoxicity, EHDI, ear and hearing care screening and intervention programmesManagement of referrals
	Community health centres	In addition to the listed services at PHC clinics:Implementation and management of aural rehabilitation programmesEarmould modifications and basic hearing aid trouble shooting
	District hospitals	Development, monitoring and evaluation of intervention plans and programmesManagement of referralsCerumen managementIdentification of neonates, paediatric and adults at risk and with established risk for hearing difficulties through EHDI and ototoxicity screening and monitoring programmes at inpatient and outpatient clinicsDiagnostic assessment of hearingManagement of hearing difficulties including aural rehabilitation post cochlear implantation and post bone-anchored hearing aid fittingEnsure appropriate referrals for advanced diagnostic assessment to other levels of careCollaboration with other team members including district health teamsRecommend school or vocational placement
Secondary	Regional hospitals	In addition to the listed services at primary and district levels:Screening for vestibular disordersDiagnostic hearing assessments which include visual reinforcement audiometry, immittance as well as electrophysiological measures such as OAEs, ABR and auditory steady state responseHearing aid assessments and objective hearing aid verificationHearing aid fittingRecommendations and referrals to appropriate levels where necessary for surgical intervention, including cochlear implants
Tertiary	Provincial tertiary hospitals	In addition to the listed services at primary, district and regional levels:Recommendations for surgical intervention, including cochlear implantsProvision of consultative clinics for cochlear implants, bone-anchored hearing aids, vestibular disorders, electrophysiology, complex disorders, auditory neuropathy spectrum disorder